COMMENTARY

Fingernail 'Surgery' for Seborrheic Keratoses

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Hello and welcome. I am Dr George Lundberg, and this is At Large at Medscape.

During 1991, at age 58, I noticed a rapidly growing, asymptomatic, deeply pigmented skin lesion with irregular margins on my cheek, just below my right eye. A dermatologic surgeon removed it by a shave excision. A large scab formed and gradually disappeared, leaving a flat white scar. The pathologic diagnosis was "pigmented seborrheic keratosis (SK)." At 25-year follow-up, there has been no recurrence. SKs are essentially always benign and of no clinical significance except cosmetic. But mine annoy me.

I subsequently have developed a large number of similar lesions, sometimes pigmented, sometimes not, on my chest, abdomen, flanks, back, neck, face, arms, and even thighs. I learned by experience that I could test any such new lesion with a firm fingernail at its edge, and quickly discern, by gauging resistance, whether or not it was another SK. If it gives way easily, off it comes with fingernail surgery, usually the nail of my right third finger. If not, it stays put. No harm, no foul.

In 2006, I reported[1] my case of successful fingernail surgery in Medscape General Medicine, with pictures, lesion all gone with no visible scar. The ensuing letters gave rise to a vigorous discussion.[2,3]

At 10-year follow-up, there has been no recurrence of that lesion nor, I might add, of additional dozens, scores of SKs that have met their fates with fingernail surgery. Did I use anesthesia? No. Aseptic technique? No. Sterile gloves? No. Soap-and-water skin cleansing? No. Alcohol swab prep? No. Post-op antibiotic ointment? No. Bandages? No. Band-Aids? No. Was healing rapid and trouble-free? Yes, always. According to McMaster Best Evidence and the Cochrane Library, skin wounds heal equally well and without infection if cleansed by tap water, sterile saline, or no cleansing at all.[4,5,6]

Did I experience bleeding? A little, briefly, depending on the depth of necessary separation of lesion from the underlying epidermis or dermis. Scarring? Virtually none. Misidentified or maltreated serious skin diseases? None recognized yet, at 25 and 10 years, and many dates in between and after. As a pathologist, I am pretty good at clinically diagnosing skin growths. And the tissue resistance test I described is really good at preventing one from trying to take off a melanoma; a basal or squamous cell carcinoma; an intradermal, compound, or junctional nevus; or a dermatofibroma, neurofibroma, or malignancy metastatic to skin.

Problems? Parts of one's back are hard to visualize clearly or reach easily. Insurance coverage for costs? Interesting question. I did not bill myself. What if I had, and requested reimbursement with proper CPT code for fingernail surgery? You tell me. I certainly saved my insurance carriers a pot full of money over the decades by not seeing dermatologists and dermatologic surgeons or having to pay pathologists.

Would I do it again? Sure. I'll do it tomorrow if needed. And I bet a lot of you physician readers are doing the same thing but maybe not telling anybody about it.

That is my experience and my opinion. I am Dr George Lundberg, at large at Medscape.

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